Introduction

This is information that I have collected on PCOS treatments, and I wanted to share
it. Who am I? I am Mary Kate Roget. I am not a doctor. I am trying to learn as much
as I can about PCOS, just like many of you are. If you find an error or omission
on this page, I will appreciate
your comments.

Disclaimer: I am not a doctor. Consult your doctor before using any treatments.
Many treatments listed here are extremely dangerous. Nothing in the FAQ should
be taken as advice. Please use this information only as a starting point
for doing more research and for topics to discuss with your doctor.

If your doctor disagrees with these treatments, look up the published
studies and show them to her. Everything here has at least some studies or other
data to back it up, or it's a mistake. If you are interested in a study reference
for any statements made in this FAQ,
send me an email.

Treatment is important because, according to
webmd.com,
"The risk of developing
diabetes is five times greater in women with PCOS. These women will also develop
diabetes at a younger age." "There is no cure for PCOS, but controlling it lowers your PCOS risks of
infertility, miscarriages, diabetes, heart disease, and uterine cancer."

I have a bias. I want to look and feel
healthy. I am not so much interested in
simply inducing ovulation as I am in weight loss and appearance. This FAQ
does not cover fertility issues. Also, I do not have high blood sugar or triglycerides,
yet. So, I do not consider treatments that increase insulin secretion to be beneficial
for someone like me, even though they may be beneficial for anyone who does have
high blood sugar. This FAQ does not cover surgical options.

There is conflicting evidence for some of the features listed above.
Everyone will have different features and symptoms. Many women will not have high
blood sugar, for example. That may come in later stages after insulin resistance
takes its toll.

As one study put it: "Polycystic ovary syndrome describes a conformational ovarian
state that may be the final common manifestation of several pathogenic pathways."

These features share many features in common with diabetes and hyperinsulinemia.

If you know of other PCOS features not listed above, please
email me.

Diagnostic Criteria

Two definitions of PCOS are commonly used today[1]:

The 1990 consensus workshop
sponsored by the NIH/NICHD suggested that a patient has PCOS if she has:

Signs
of androgen excess (clinical or biochemical)

Oligoovulation

Other causes of PCOS are excluded

In 2003 a consensus
workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if 2
out of 3 criteria are met and other causes of PCOS are excluded:

Oligoovulation or anovulation

Excess androgen
activity

Polycystic ovaries by ultrasound

Despite the name, not all women with PCOS have polycystic ovaries
and they are unnecessary for diagnosis. "Witness the changing definition of 'polycystic ovaries'
and the 10% to 30% of women with PCOS who do not demonstrate polycystic ovaries
on ultrasound."[2] "In the full-blown syndrome (classic PCOS), the clinical symptoms
provide the most powerful indication and the association of the three components
(hyperandrogenism, anovulatory dysfunction and metabolic abnormalities) has a
strong diagnostic potency."[3] Hyperandrogenism is a key feature, yet "only half
of women with PCOS exhibit elevated serum free T concentrations."[4]
So, blood tests are great and help in understanding what is going on
but they are actually not necessary to diagnose PCOS,
except maybe to rule out other causes.

Treatment Target

The treatment target is basically to reverse the features listed above. Some features
are more upstream from others. Elevated C-Reactive Protein can be caused by increased
TNF-alpha. Low SHBG is probably a consequence of hyperinsulinemia which inhibits
its production. TNF-alpha may increases MMP-9. High blood sugar results, over time,
from insulin resistance and hyperinsulinemia. But, many are closely interrelated,
and there is no consensus as to what exactly is the root cause. High insulin causes
high testosterone, and the reverse is also true. High TNF-alpha causes increased
insulin, and the reverse is also true. Most of these features are so tightly related
that if you treat one, you are likely to improve all the others. Lowering lipid levels,
improves antioxidant status and decreases inflammation and increases insulin sensitivity.
Insulin inhibits SHBG production, so anything which lowers insulin levels should
also improve SHBG levels. There are many more examples. The one most people know
is that if you lower insulin, you lower testosterone, and the reverse is true to
a lesser extent. Insulin resistance appears to be the most important feature, but
it does not explain everything.

The two main targets are androgens and insulin. Most treatments are targeted at blocking
androgens and increasing insulin sensitivity.

Increasing insulin sensitivity is good for everyone, and it appears to be especially
important for those of us with PCOS. You cannot have too much insulin sensitivity.
Insulin sensitivity generally decreases with age and is why the risk of developing
Type 2 diabetes increases with age. There is no single treatment that will give
you perfect insulin sensitivity. There are many treatments that increase insulin
sensitivity somewhat and to varying degrees. One should do as much as possible
to try to increase insulin sensitivity and not pin your hopes on any single treatment.

Depression and bipolar disorder are common in PCOS. These neurological symptoms
have some features in common with PCOS: insulin resistance, high blood sugar,
increased TNF-alpha, C-Reactive Protein, homocysteine, lowered omega-3 fatty
acids, lowered Magnesium, and dysregulation of the hypothalamo-pituitary-gonadal
axis. There is evidence that treating these features can improve depression,
along with PCOS. There is also evidence that any effective treatment for PCOS
will improve depression as well.
See my depression & mood disorder references page.

Treatments

Doses listed below are per day. Many supplements are better to
take in divided doses, 2 or 3 times a day, as many have a short half-life.

You may notice that some doses listed here are much higher than the recommended daily
value. RDA or RDI dosages for nutrients are the amount needed to prevent disease.
RDI dosages are not designed to treat any disease or disorder like PCOS or
diabetes. If you want any vitamin, drug, herb or nutritional supplement to treat
PCOS, you must be aware of the dose required for an effect. At the same time,
be aware of doses that may be toxic.

If your supermarket multivitamin has 1mg of something, and here is listed 1000mg,
it should make you concerned, and you should seek out more information and
ask your doctor. However,
just because your multivitamin contains something, does not mean that it will
have any effect. If a multivitamin's dose for a particular nutrient is nowhere
near the dose shown to benefit PCOS, it is probably completely worthless as a
treatment for PCOS.

Each treatment is given my personal and totally subjective star rating based on
5 stars. I try to base the ratings on the published studies rather than on antidotal
evidence. There may be treatments here that get very enthusiastic praise from
people, and I only give them three stars or less. In that case, it's because
I could not find studies to support the praise, but that doesn't mean the proponents
are wrong.

It has been noted that several treatments for insulin resistance take more than
a month, to several months, to see any benefits. In fact, some treatments, especially
those that increase insulin sensitivity may initially, briefly, increase body
weight due to anabolic and fat storage effects of insulin. Keep that in mind
if you are judging the effectiveness of any new treatment.

Some treatments include references, others were omitted to save space. I have
collected over 400 references. If you are interested in a study reference for
any statements made in this FAQ,
send me an email.

Disclaimer: I am not a doctor. Consult your doctor before using any treatments.
Many treatments listed here are extremely dangerous.
Dosages below may be inaccurate. Please use this information only as a starting
point for doing more research and for topics to discuss with your doctor.

*****
5-Star Treatments

Exercise:
30-45 minutes (cardio & resistance)
Star rating: *****

Lifestyle, diet and exercise can be very effective and are often considered the first-line treatment.
If you're not exercising or you're eating a high-calorie or high-glycemic-index
diet, that's the first thing to correct. Lifestyle changes have been shown to
be more effective than Metformin. Of course, you can add other treatments on
top of lifestyle for further improvement.

Exercise has been shown to increase insulin sensitivity and reduce abdominal fat,
blood sugar, and insulin levels.
It is much better to exercise a little every
day than a lot every few days. Among other things, exercise will burn off
blood sugar and prevent it from staying elevated and causing inflammation
and all it's other negative effects. You cannot make up for skipped days and
the effect on blood sugar by working out harder the next day. In the study referenced
below under Metform, the lifestyle group engaged in physical activity of moderate
intensity, such as brisk walking, for at least 150 minutes per week.

Cardio training and resistance training each show destinct benefits. The quote below is from
a review article that talks generally about many ways to increase insulin
sensitivity. You can read the full article here.

Quote: "Even an exercise routine as simple as incorporating brisk walking four times weekly
dramatically improves endurance fitness, decreases body fat stores, tends to reduce food
consumption, and decreases insulin resistance. Based on available evidence
it is likely an optimal program for improving insulin sensitivity might,
in addition to an aerobic component like walking, aim even more specifically
to selectively deplete body fat
while maintaining or building lean tissue by incorporating resistance training."

Quote: "The results obtained indicated that ovarian morphology was almost
normalised in the PCO exercise group; NGF mRNA and protein concentrations
were normalised in the PCO exercise group; high numbers of NGF receptor expressing
cells in PCO ovaries were lowered by exercise; and the number of immunopositive cells
of the different AR subtypes were all reduced after exercise in the PCO group."

Monounsaturated Fats or polyunsaturated fat should replace Saturated fat (For
example: replace butter with olive oil). Diets high in monounsaturated fats have
been shown to increase insulin sensitivity. It will also slow digestion and lower
the overall glycemic index of a meal.

High fiber diets increase SHBG which binds to and lowers free testosterone.
Fiber can lower PAI-1. Various fibers have also been shown to lower cholesterol
and blood lipids.

Unrefined, whole foods will generally have a lower glycemic index, more
fiber, and more nutrients.

Adequate protein diets have benefits. Low protein diets are shown to
contribute to insulin resistance and adversely affect body weight. Compared to
low protein diets, higher protein diets have been shown to increase weight loss
and to help maintain that weight loss. Protein also slows digestion and lowers
the overall glycemic index of a meal. Unfortunately, a high protein diet
was shown to lower SHBG. Interestingly, carb intake itself was not associated
with SHBG levels in one study.

Antiandrogens are not covered in depth here. There's a lot more to know than I'm going
to cover. Antiandrogens have been shown to substantially
improve virtually every symptom of PCOS. No other treatment is more effective
for hirsutism or hair loss. In fact, most other treatments are really not very
effective for hair. Nonetheless, they have their drawbacks and side effects. Your doctor
would probably have you take an OCP with an antiandrogen because of the
birth defects they can cause, especially in males (males need those androgens).
So, they are not an option if you are TTC.

When using antiandrogens for androgenic hairloss, it's important
to understand that the hair cycle is long, and it is practically impossible to see new hair
growth before 3 to 6 months. Also, the hair cycle progresses through its stages
in order. Hair enters the resting (telogen) phase, then the hair is a shed before
a new hair starts growing (anagen). Any hair in telogen must fall out before
it will start growing again. This means that any hair loss treatment that works
will probably be associated with initial shedding as new hairs come out of telogen.
This is naturally alarming to see. If you indeed have androgenic hair loss,
and you are using something that is proven to treat
androgenic hair loss, like any strong antiandrogen, and you are
worried it is making things worse after a few weeks, it's
probably only temporary (of course, you
should ask your doctor in case it's something else). Also, if
you started using a new treatment yesterday or last week and it looks like
you have more hair, you're kidding yourself - it's the humidity or your shampoo
or you're just in a good mood. The lesson here is, use something that is proven
to work and then try not to think about it for a few months. Don't think you're
going to try something for a couple weeks just to see
if it works.

A lot of studies on hair loss and hirsutism sound impressive, but really
they aren't. In medical studies, the words "effective" and "significant" may only
mean there was a tiny effect that was statistically significant.
The word "significant" does not mean "a lot," it only
means the effect, however small, was not due to chance. So, you can read a study
that claims "this was an effective treatment for hair loss", and "there was significant
new hair growth", and what really happened was a tiny, "non-cosmetic"
improvement that you can't even see. The improvement could be
a lot, but you have to read the details to know.

It's my speculation, and from reading forums, that one could use an antiandrogen
temporarily for, say, a year or two, and then taper off and stop taking it. After
some time on an antiandrogen, you would reverse a lot of the hyperandrogenic
symptoms. Then you could stop and hopefully the symptoms would not come back
as long as you continued with your other treatments to keep your weight, insulin
and androgens low, like with diet, exercise and insulin sensitizers. Because,
if you're androgens are low enough and being kept in check with other treatments,
your symptoms shouldn't come back to any large degree. At least, I hope. I could
be wrong and I don't have proof.

Flutamide (Eulexin) has many articles demonstrating liver damage and death.
It's too bad because Flutamide is a very
potent antiandrogen. However, in almost every case they are at doses above 350mg/day.
Several studies show efficacy in PCOS at low to very low doses of flutamide (62mg
to 250mg per day), and suggest that these doses are safe. If you take it, your
doctor will probably watch your liver closely with blood tests. There is no doubt
that it can greatly improve PCOS symptoms. Flutamide is the strongest antiandrogen
and the most effective treatment for
hirsutism and hair loss that I know of (except maybe for Dutasteride).

Quote: "After only 6 months of therapy, flutamide caused a maximal reduction in
the hirsutism score to a value within almost normal range; during the same period,
spironolactone caused only a 30% reduction of the hirsutism score. Whereas flutamide
caused a dramatic (80%) decrease in total acne, seborrhea, and hair loss score
after only 3 months of therapy, spironolactone caused only a 50% reduction in
acne and seborrhea, with no significant effect on the hair loss score."

The enzyme your liver uses to process Flutamide is the same enzyme used to process
caffeine, Prozac and Echinacea. It may be a good idea to avoid things
that inhibit the CYP1A2 liver enzyme, if you are taking Flutamide. However,
even though caffeine is metabolized by CYP1A2, it also increases the activity
of CYP1A2 at the same time, and thus "caffeine increases its own metabolism".
So, whether caffeine is good or bad to take with Flutamide is unclear - I doubt
it matters. One study notes that "CYP1A2 index was 33% decreased in women who
used oral contraceptives." Also,
the antioxidant carotinoid, Astaxanthin has been shown to be a strong inducer
of CYP1A1 and CYP1A2 liver enzymes. This implies Astaxanthin may help detoxify
the byproducts of Flutamide. But, I have no idea if any of this matters in practice,
and I may be confused.

Spironolactone (Aldactone) is a good antiandrogen. It is safer than Flutamide
(depending on the dose),
but typically a little less effective. This drug is a potassium sparing diuretic
and it also blocks aldosterone. In contrast to the glowing reference for Flutamide
above, several studies showed no significant difference between
Flutamide and Spironolactone - both were effective.

Dutasteride (Avodart) is a 5 alpha-reductase inhibitor (both
types 1 and 2) that reduces dihydrotestosterone (DHT). It is the most potent
5-ar inhibitor and will greatly lower DHT levels. Unfortunately, there are not
many studies on Dutasteride yet and none specifically on hirsutism. The following
case study shows a full reversal of androgenic hair loss.

Quote: "After 6 months of therapy, significant improvement
was observed and after 9 months the clinical diagnosis of androgenic alopecia
could no longer be made in this patient."

Finasteride (Proscar or Propecia) is also a 5 alpha-reductase inhibitor
(type 2 only). Finasteride is less potent than Dutasteride. It probably has the
least side effects, and is the least effective, but studies show that it has
merit.

Saw Palmetto extract (Serenoa Repens) may have effects similar to Finasteride.
Two studies suggest it may be beneficial for hirsutism based on Saw Palmetto's
ability to inhibit 5 alpha-reductase. A recent study comparing Saw Palmetto to
Finasteride found Saw Palmetto was completely ineffective. Previous studies showed
some effect, however. I have grouped this here with the antiandrogens, but I'd
only give it 3-stars. My feeling is, if you want to take a 5-ar inhibitor, take
one that really works.

Metformin is a glucose lowering and insulin sensitizing drug for the treatment
of diabetes. Metformin has been shown repeatedly in published studies to increase
insulin sensitivity, lower androgens, lower C-Reactive Protein, lower PAI-1,
and raise D-Chiro-Inositol and SHBG in PCOS. Numerous studies show improvement
in most every PCOS symptom with doses of 1500-2500mg. There are too many studies
to list. Virtually every study on PCOS in the last 10 to 15 years discusses Metformin.
Anecdotal reports in various PCOS forums suggest 2000mg or more may be necessary
for some. Unfortunately, Metformin lowers folate and B12, and raises homocysteine
and TNF-alpha. So, it would be wise to supplement Folate and B12, and possibly
other homocysteine lowering agents, like B6, along with agents to lower TNF-alpha.
Also, it may be unwise to supplement folate without B12, as folate can mask symptoms
of B12 deficiency.

Often, benefits begin to appear after months, not weeks.

Metformin is a very safe drug. However, it does have some degree of toxicity.
Kidney toxicity, and less commonly, liver toxicity, is possible.

In the study above, involving 3,234 people over an average of 2.8 years, Metformin
(1700mg) alone was compared to a placebo, and to lifestyle intervention (diet & exercise).
The results showed that lifestyle decreased the incidence of diabetes by 58%,
and Metformin by 31%. So, Metformin was good, but diet and exercise was better.
The number of deaths during this study was:

The number of deaths was not statistically significant.
What's interesting, if you Google Metformin and life extension,
you will find a lot of discussion
about using Metformin to extend lifespan. There are actually people taking it
who do not have diabetes or PCOS and are perfectly healthy and they
take it because insulin sensitivity is one of the most important markers of lifespan.
Metformin was shown to extend lifespan and decreased the incidence and size of
mammary tumors in mice.

Reference: Anisimov VN, et al. Effect of metformin on life span and on the development of spontaneous mammary tumors in
HER-2/neu transgenic mice. Exp Gerontol. 2005 Aug-Sep;40(8-9):685-93.

To avoid nausea, it may help to start with a low dose and increase the dose very
slowly. Nausea often goes away with time. The 'XR' form may also help reduce
nausea. If you start out at some dose and experience nausea then talk to your
doctor about lowering your dose temporarily and slowly increasing after you give
your body a chance to adjust. Just because you can't tolerate a particular dose
now doesn't mean it's just wrong for you or that you will never be able to tolerate
it. Maybe, maybe not, but unless you give it a chance, you won't know.

Metformin may also cause diarrhea. A study notes that, unlike nausea, diarrhea
may occur later even when the dosage has been stable over a long period.

These are insulin sensitizing diabetic drugs. These have been shown repeatedly
to increase insulin sensitivity, SHBG and other hormonal parameters, and improve
PCOS symptoms. They were shown to decrease PAI-1. They can be used in combination
with Metformin since they have a different mode of action. The combination has
been shown to help PCOS subjects who were resistant to Metformin therapy alone.

These are a class of drug called thiazolidinediones. Actos and Avandia appear
to be safer than another discontinued thiazolidinedione, Rezulin. This class
of drug is relative new. They are prescribed less often than Metformin for a
couple reasons. There are still fears of toxicity and unknown long-term side
effects. Also, these drugs do not appear to improve weight as Metformin can,
and there may be weight gain with Avandia.

Byetta's active ingredient, Exenatide, works by mimicking the effects of a human
hormone called GLP-1, which is normally released after meals, stimulating digestion
and insulin production. GLP-1 also discourages the liver from producing too much
sugar. Studies show it increases insulin sensitivity. Stimulating insulin production
is bad, unless you're not producing enough insulin. Reducing hepatic glucose
release is good and is one of the things Metformin does. As long as the increased
insulin is not more than necessary, and is only increased when there is not enough,
it should be all good. Byetta is currently being tested for PCOS in a clinical
study. We will know more when further studies are published. A major downside
is that this is taken by injection just before breakfast and dinner.

****
4-Star Treatments

Oral Birth Control Pills:
Star rating: ****

OCPs are not covered in-depth here either. There are some good ones that are more
antiandrogenic than others. For many years, oral contraceptives were the
standard, first-line, treatment for PCOS. They can actually
help with almost every symptom. They are not worthless, and some are better than others.
Some have evidence of increased insulin resistance.
So, you need to shop around if you want this treatment.
Unfortunately, these may raise C-Reactive Protein
and deplete Vitamin C.

Perhaps the biggest reason to take these is that they can significantly increase SHBG,
which decreases free testosterone.

Precose: (Acarbose)
50-100mg/meal
Star rating: ****

Miglitol: (Glyset)
50-100mg/meal
Star rating: ****

These prescription drugs have been shown to be effective in the treatment of PCOS
by decreasing glucose load which resulted in decreased insulin response, lower
androgens and LH, and increased SHBG. These drugs slow the digestion of starches
you eat by inhibiting alpha-glucosidase. You take them with the first bite every
meal. You typically start out at a low dose until you get used to it and work
up to 50-100mg per meal. Side effects were frequent abdominal distension, diarrhea
and flatulence. Side effects may lessen over time.

If you take these drugs it is important to understand that they will slow down
the digestion of most starches and complex sugars, but not glucose, fructose
or corn starch.

Quote: "This is the first report showing a reduction of the acne/seborrhoea score
in hyperinsulinaemic patients with PCOS treated with acarbose. This improvement
was associated with a significant decrease of the insulin response to oral glucose
load and of LH and androgen serum concentrations and with a significant rise
of sex hormone binding globulin concentration."

Quote: "A low dose of acarbose
administered to obese patients with PCOS promotes a reduction in free androgen
index and BMI and an increase in SHBG, with improvement of hirsutism and of the
menstrual pattern, and is well tolerated by patients."

D-Chiro-Inositol:
1200mg
Star rating: ****

This is shown in several studies to improve insulin sensitivity and PCOS symptoms.
Why did the owner of the patent on its use for PCOS, Insmed, decide not to market
it? This is Insmed's statement on record:

"In recently completed clinical trials in patients with PCOS, INS-1 [(D-Chiro-Inositol)] was
safe and well tolerated but did not achieve statistical significance on its primary
efficacy measures. Although an overall increase in ovulation rates was not achieved,
an increased number of pregnancies occurred in the INS-1 treated patients."

This is really all we know. This was surprising since there are several other
studies which found it was effective, including Insmed's previous phase I
and IIa studies which involved more than 1000 subjects. Off record, the company
is rumored to be trying to market DCI as a dietary supplement. Also, the doctor
who discovered DCI's involvement in insulin action, Dr. Joseph Larner, told me
by email that he is trying to make it available as a dietary supplement. The
company is also reported to have said, off record, that the reason to discontinue
DCI was a business decision. As late as Feburary 2006 it continues to
be studied in relation to PCOS.

I suspect that the business decision to discontinue FDA approval may be because
it is not more effective than Metformin, or because you could take 3x the
amount of Pinitol and get the same effect.

Often (in studies that showed effectiveness), benefits began to appear after months,
not weeks, as is the case with Metformin.

D-Chiro-Inositol is something that your body makes. Some foods have it,
but in minute amounts unless it is concentrated. The body will convert myo-inositol
(the common form of inositol) to DCI. There is one study and one patent that
suggests myo-inositol can help with insulin sensitivity too. But, it is also
known that those with diabetes and PCOS are often inefficient at converting myo-inositol
to D-Chiro-Inositol. This results in a higher ratio of myo-inositol to D-Chiro-Inositol.

Pinitol (methyl-D-chiro-inositol), the methyl form of DCI, appears to be converted
33% to DCI. That says that 3600mg of Pinitol should be
equivalent to 1200mg DCI.

NAC is the acetylated form of the amino acid L-Cysteine. Several studies show
benefit in PCOS at 1200-1800mg. NAC has many other studies showing benefit in
diabetes. It can improve insulin sensitivity. It lowers TNF-alpha, suppresses
MMP-2 and MMP-9 and inhibits VEGF. It increases Glutathione. It is a potent antioxidant.
It can reduce homocysteine. Normally it is a good idea to take amino acids on
an empty stomach so they will not compete for absorption with other protein.
However, NAC can cause nausea if taken on an empty stomach, which shouldn't happen
if you take it with food in divided doses.

As of this date, there are no adequate studies of NAC administration in pregnancy.

There are at least three human studies that used 1800mg NAC which showed positive
results. The first study listed below found that doses below 1200mg were beneficial,
but in healthy people, 1200mg acted as a pro-oxidant and may lower glutathione.
However, other studies at these doses and higher, including ones that post-date
that study, found the opposite effect. Furthermore, PCOS is associated with an
increased oxidative state, and if NAC can improve the parameters in PCOS, then
it seems likely it would lower that oxidative stress caused by PCOS.

NAC may increase urinary zinc excretion. A molybdenum deficiency (which is very
rare) can cause an accumulation of sulfite from the catabolism of L-cysteine.

Quote:"Insulin [area under curve] after [oral glucose tolerance test] was
significantly reduced, and the peripheral insulin sensitivity increased after
NAC administration, whereas the hepatic insulin extraction was unaffected. The
NAC treatment induced a significant fall in T levels and in free androgen index
values. In analyzing patients according to their insulinemic response to [oral
glucose tolerance test], normoinsulinemic subjects and placebo-treated patients
did not show any modification of the above parameters, whereas a significant
improvement was observed in hyperinsulinemic subjects. CONCLUSION(S): NAC may
be a new treatment for the improvement of insulin circulating levels and insulin
sensitivity in hyperinsulinemic patients with polycystic ovary syndrome."

Many studies show improved insulin sensitivity at doses of 600-1800mg. Lipoic
acid lowers TNF-alpha and suppresses MMP-9 and prevents increased VEGF. In some
studies, doses below 600 were found to be ineffective, where higher doses were
effective. It is a potent antioxidant. The other benefits are too numerous
to list. This is sometimes characterized as an insulin mimic. If it is available,
R-Lipoic Acid would be a better choice, and half the dose could be used. Lipoic
Acid can compete with biotin, so you may want to take extra biotin with this.
Lipoic acid has a short half-life and a couple studies suggest that sustained
release tablets may have an advantage. However, another theory says that immediate-release
(or "pulsed release")
lipoic acid has an advantage by overwelming the liver and thus increasing
plasma levels since it has such a high first-pass metabolism.

Several studies show that when GLA is combined with Lipoic Acid it strongly enhanced
the glucose lowering and insulin sensitizing effects beyond using either one
individually.

Lipoic Acid has been suggested as a treatment for depression in metabolic disorders.

All omega-3 oils are not the same. There are a huge number of studies showing
a huge range of benefits from fish oil and especially from the EPA and DHA fatty
acids. Other oils, like flaxseed oil, have far less evidence of benefits, and
nowhere near the degree of benefit seen from fish oil. Despite being an omega-3
oil, Flax does not contain the omega-3 fatty acids EPA and DHA found in fish
oil. Many studies show benefits from these specific isolated fatty acids. Flax
primarily contains the omega-3 fatty acid alpha-linolenic acid which is partly
converted to EPA by the body, and virtually none is converted to DHA. The EPA
created by taking Flax can have some of the same benefits as Fish oil. However,
fish oil will more effectively raise blood levels of EPA, and fish oil includes
DHA which has shown similar, and distinct benefits. Flax lignands (found in flaxseeds
not pure flax oil) may have additional benefits, however.

It's probably best to take a fish oil concentrate to increase the amount of EPA
and DHA in the fish oil and avoid excess vitamin A and D. Some supplements have
names like "Max EPA" or "Super EPA". Using a concentrate will require far fewer
pills than whole fish oil.

There have been no reports of serious adverse events in those taking EPA supplements,
even up to 15 grams daily, for prolonged periods of time. Those side effects
that have been reported include mild gastrointestinal upsets such as nausea and
diarrhea, halitosis, eructation, "fishy" smelling breath, skin and even urine.
The blood-thinning effects can cause occasional nosebleeds and easy bruising.
For many people, the gastrointestinal side effects often disappear after a few
weeks. If you are bothered by the gastrointestinal effect, it is sometimes
recommended to start with one pill per day, and very slowly
increase the number of pills over weeks.

Krill Oil is another option that may have similar benefits. The studies on Krill Oil
are impressive, but I doubt any are peer-reviewed.

A study using Calcium and Vitamin D showed improved PCOS symptoms. Their are many
other studies on using both together, and using them independently which show
improvement in diabetes, insulin resistance, hyperinsulinemia, and glucose tolerance.
Several studies show impressive weight loss with calcium supplementation. Vitamin
D is also effective at lowering TNF-alpha. Vitamin D deficiency increases C-Reactive
Protein, MMP-9 and MMP-2. Calcium may also be helpful in treating PMS.

Coral calcium, which also contains magnesium, has gotten a lot of hype but so
far there is no evidence that it is better absorbed or has any other benefits
over the citrate or some other forms which are proven to be well absorbed. If
you are allergic to shellfish, the Mayo Clinic says coral calcium can trigger
an allergic reaction. Some people claim there is a potential for coral to contain
heavy metals. Low levels of lead were measured in some samples of coral calcium,
but they were within FDA limits.

Calcium is not absorbed very well, in general. The absorption of Calcium Bisglycinate
(44% absorption) > Calcium Citrate Malate (CCM) (36%) > Calcium Citrate
(24%) > Calcium Carbonate (23%) > Hydroxyapatite (17%) > Calcium Hydoxide/Oxide
(10%). You can't really compare the percents listed here because some of them
are the percent absorption with meals and others were measured on an empty stomach.
But, it should give you a rough idea. There is some evidence that Calcium carbonate
cannot be absorbed and utilized until it is converted to calcium chloride in
the stomach, and using stomach acid to convert it will interfere with B12 absorption
and digestion of foods. The absorbability of calcium citrate is between 20% and
100% better than calcium carbonate, depending on who you ask.

A study in JAMA found that calcium absorption from supplements increases about
10% when taken with meals. However, this may be less of a factor with Calcium
Citrate than to other forms, as Citrate basically comes with its own acid to
aid digestion.

It's better to take 500mg or less at a time. The more you take at once, the
less you absorb. As you take more, absorption becomes less and less efficient.
Taking calcium with meals supposedly reduces the risk of kidney stones.

Quote: "Vitamin D repletion with calcium therapy resulted in normalized menstrual
cycles within 2 months for seven women, with two experiencing resolution of their
dysfunctional bleeding. Two became pregnant, and the other four patients maintained
normal menstrual cycles. These data suggest that abnormalities in calcium homeostasis
may be responsible, in part, for the arrested follicular development in women
with PCO and may contribute to the pathogenesis of PCO."

Chromium:
1000mcg (1mg)
Star rating: ****

Many studies show strong evidence of improved insulin sensitivity. Chromium may
reduce fasting insulin levels. Several studies show increased fat loss, yet other
studies found no effect on weight. Deficiency can cause insulin resistance. Chromium
may lower total cholesterol and LDL-cholesterol. Chromium may have synergy when
taken with Biotin. Several studies show no effect from 200mcg per day, while
studies on 800 to 1000mcg have shown effect.

In vitro studies and high-dose in vivo animal studies found Chromium Picolinate
(as opposed to Polynicotinate or other forms) increased chromosomal damage. Other forms of Chromium
were shown not to cause this DNA damage. However, in vivo human studies using
various measures of DNA damage have not yet found Chromium Picolinate to cause
this DNA damage. If you choose to take Chromium, you might as well avoid the
Picolinate form and instead take the Polynicotinate, GTF, or Chelavite (glucose-tolerance-factor,
chromium-niacin, or chromium-niacin-amino acid chelate) forms. The Chelavite
form may be the most absorbable form.

Chromium was recently studied specifically for PCOS.

Quote: "Trivalent chromium (1000 microg), as chromium picolinate, given without change
in diet or activity level, caused a 38% mean improvement in glucose disposal rate in
five obese subjects with polycystic ovary syndrome who were tested with a euglycemic
hyperinsulinemic clamp technique. This suggests that chromium picolinate, an
over-the-counter dietary product,
may be useful as an insulin sensitizer in the treatment of polycystic ovary syndrome."

***
3-Star Treatments

I could not find many clear descriptions of its benefits or what improvements
to expect in PCOS symptoms. Many people are enthusiastic about Natural Progesterone
Cream and find it very helpful, and those people would give it a higher rating
than I did.

Oral Progesterone appeared to work better in one study that compared the Cream
and Oral forms, but that may have been only because of the dose of cream used.
There is evidence that both can lower LH and increase SHBG. There is some evidence
that they may improve insulin levels as well. Several studies suggest it does
not improve androgen levels. It has potential to help with many PCOS symptoms.
It appears most useful for inducing ovulation and improving menstrual regularity.
A study that used the cream at 100mg twice a day appeared to work better than
50mg twice a day. But, you don't use Progesterone every day of the month. If
you plan to use this, you will need more information than is discussed here.

I am not a big fan of this treatment, partly because the theory of Progesterone
deficiency does not appeal to me as much as the theory of reduced sensitivity
to progesterone and estrogen. Personally, I would rather treat the sensitivity
problem rather than treating it as a deficiency. But, I could be wrong.

Quote: "The mean serum LH concentration had fallen significantly after 8 days
of treatment, and continued to fall progressively until the end of progesterone
administration. Serum LH concentrations had fallen into the normal follicular
phase range by 14 days."

Green Tea: (epigallocatechin gallate, EGCG)
270mg
Star rating: ***

Many studies show improved insulin sensitivity. It lowers TNF-alpha and MMP-2
and MMP-9. It is a potent antioxidant. It may increase SHBG. A study shows 90mg EGCG
taken 3 times per day resulted in impressive weight loss. EGCG (epigallocatechin gallate)
is a major polyphenol or catechin in green tea that has been tested in may studies
and is thought to be one of the most active ingredients.

Every Green Tea extract will have a different concentration of EGCG. Some Green
Tea extracts are only 10% EGCG. Some contain caffeine and some are (mostly) decaffeinated.

The study below tested green tea extract in PCOS and found no significant effect.
I haven't read the full study. I'm sure they studied it because they thought
it would be effective because of the many of studies showing increased insulin
sensitivity and other benefits in humans and animals. If
I'm going to weigh all the evidence, I can't throw out
green tea because of one study. It's certainly an interesting result and it begs for an explanation.

These are phytoestrogens. This is not flaxseed oil, though you can find high-lignan
oil. A study found "Three anovulatory cycles occurred during the 36 control cycles,
compared to none during the 36 flax seed cycles." Lignans may increase SHBG.
They may be 5 alpha-reductase inhibitors, although the evidence is not strong.
These may have many of the same benefits as soy isoflavones.

Soy Isoflavones:
Star rating: ***

These are phytoestrogens. There is evidence these can increase SHBG. They may
inhibit TNF-alpha. Soy Isoflavones have been studied for prevention of breast
cancer. However, there are few studies on their possible benefits in PCOS. One
study shows it may contribute to menstrual irregularity. Most of the benefits
are antidotal, but that may only mean the science needs to catch up.

Cinnamon:
1/2 teaspoon
Star rating: ***

The active chemical in Cinnamon is MHCP or methylhydroxychalcone polymer. This
has been shown to lower blood glucose levels. Cinnamon has been in the news recently,
but it has been known about for some time. The cinnamon used in the 2003 study
in Diabetes Care was actually Cassia (Cinnamomum cassia) and not "true" cinnamon
(Cinnamomum zeylanicum, or Cinnamomum verum). According to reports, the authors
said the active agent is in all varieties sold as the spice. Cassia is cheaper
and more common in the US. In the US, but not every country, Cassia is allowed
to be sold and called Cinnamon. The authors suggested that 1/4 to 1 teaspoon
daily may be useful for type 2 diabetes, but it's too soon to know for sure.
Specifically, the study used 1, 3 or 6 grams of cinnamon, and all doses showed
a response within weeks. It's recommended not to use cinnamon while pregnant,
but I don't know why.

Cinnamon was also found to lower triglycerides, LDL cholesterol, and act as an
antioxidant.

One study finds, "cinnamon supplementation does not improve glycemic control
in postmenopausal type 2 diabetes patients." Other studies note the effect
is only moderate.

In the diabetes newsgroups, many people have tried it, people who watch their
blood glucose very closely, and their results were nil, unimpressive, or even
negative.

Many studies show improved glucose tolerance and improved insulin sensitivity
at doses of 8-16mg. These doses are much larger than you will find in a multivitamin.
When taking large doses of any one B vitamin, it's usually recommended to take the rest
of the B-complex with it. It may be a good idea to supplement with Biotin if
you are taking either Lipoic Acid or Vitamin B5.

Vitex: (Agnus Castus; Chasteberry; Chaste Tree)
Star rating: ***

There are many enthusiastic users of Vitex who would give it a higher rating.
Studies show it can increase LH, lower FSH, and thus raise progesterone. The
raised progesterone raises the progesterone/estrogen ratio which may improve
menstrual regularity and ovulation. Some experts argue that in the case of PCOS,
Vitex works more by normalizing hormone levels than by simply increasing LH.
It has also shown to help PMS symptoms. One study found reduced acne. The common
advice is that this herb starts to work slowly over months.

Vitex has also been shown to lower prolactin, which is increased in PCOS and may
be partly responsible for infertility. There is evidence that Vitex decreases
prolactin by virtue of it being a dopamine agonist. Prescription dopamine agonists
like bromocriptine or cabergoline, have been shown to help induce ovulation,
but they are not very effective at treating PCOS overall.

The reason I did not give this a higher rating is the lack of evidence of weight
loss, improved hirsutism, insulin sensitivity, or lowered insulin levels. Also,
it may increase LH which is already increased in PCOS and lower FSH which is
already decreased in PCOS. But, again, its been suggested that Vitex may not
work this way in PCOS. Nonetheless, it appears to have benefits, and it may be
that some of the benefits simply have not been studied yet.

Interestingly, Vitex appears to stimulate melatonin secretion, which suggests
that it could make a person sleepy.

**
2-Star Treatments

Kidney Bean Extract: (Phaseolus Vulgaris Extract)
Star rating: **

This is a common ingredient in "carb blocker" type products. It inhibits the digestion
of starch by inhibiting alpha-amylase. It has been shown in some studies to improve
glucose metabolism. It may lower triglicerides. You take this with your first
bite of each meal. A study by the Mayo Clinic confirmed that kidney bean extract
can work to lower blood sugar, but that the commercial products they tested were
not potent enough to have an effect. I don't know if there is an effective brand
or not, or how much you would have to take.

Vinegar:
with food
Star rating: **

In a few studies, vinegar was shown to reduced the postprandial glucose and insulin
responses probably by slowing digestion.

These are different types of soluble fibers. They can help lower postprandial
insulin secretion and keep blood glucose lower by slowing
gastric emptying.

Pycnogenol: (pine bark extract)
200mg
Star rating: **

This has been shown to have some antidiabetic activity, including lowering blood
glucose. It's a proven antioxidant. There is supposed to be a study showing that
when combined with Metformin it lowers blood glucose more than with Metformin
alone. The following study noted maximum improvement at 200mg, and no more improvement
at 300mg.

Like Grape Seed Extract, this contains Procyanidins, so the two probably share
the same effects.

Grape Seed Extract:
200mg
Star rating: **

The main ingredient in Grapeseed Extract are Procyanidins, which is the same as
Pycnogenol. Grape Seed Extracts may also contain a small amount of resveratrol.
There are only a few studies related to insulin in rats and in vitro. So, the
evidence is not strong, but taken with the evidence of Pycnogenol and it's better.
It's a great antioxidant.

Sage: (Salvia officinalis)
Star rating: **

There are a couple in vitro and animal studies showing sage spice increases insulin
sensitivity.

Several studies show improved insulin sensitivity in animal models. Taurine can
act as an antioxidant. It can decrease TNF-alpha and VEGF. It is neuroprotective.
Taurine is lower in diabetics. Although the evidence is weak, it can increase
the production of serotonin, and may be effective at treating bipolar disorder,
depression, and anxiety. It has a calming effect on the nervous system. One study
suggests that it may be beneficial to take Taurine with NAC. Because, on one
measure of oxidation, Taurine by itself showed neutral or negative results, but
when combined with NAC it was more beneficial than with NAC alone.

A study shows Magnesium deficiency in PCOS. There are many studies showing improvement
in diabetes, hyperinsulinemia, and impaired glucose tolerance with doses of 500-2500mg.
Deficiency can increase MMP-2 and MMP-9 activity, and TNF-alpha. A ratio of 2:1
(calcium to magnesium) is often recommended. In diabetes, and this probably includes
PCOS, the recommendation is that the ratio should be closer to 1:1.

Several studies show magnesium levels to be significantly reduced in
depressed
patients. Also, the calcium:magnesium ratio is often increased in
depression.
It has been shown to help treat several PMS symptoms, including mood changes.

Magnesium can act as a laxative. If you plan to use a high dose, it may be a
good idea to start slow. Some people cannot handle more than 300mg. Magnesium
glycinate is a form that is supposed to be the most absorbable and have the least
laxative effect. Magnesium citrate should have less of a laxative effect than
magnesium oxide.

GLA is an omega-6 fatty acid normally made by the body by converting linoleic
acid. Several studies show that when GLA was combined with Lipoic Acid it strongly
enhanced the glucose lowering and insulin sensitizing effects beyond using either
one individually. The strongest argument for its use in PCOS is in this combination
with Lipoic Acid.

There are conflicting studies on whether or not GLA by itself can increase insulin
sensitivity. GLA can inhibit TNF-alpha and other inflammatory cytokines, which
should, in theory, help improve insulin sensitivity, and is probably good for
PCOS in any case. Several studies show benefit for diabetic neuropathy. When
used alone, GLA may worsen lipid profiles. GLA has shown benefit in treating
PMS in some studies. In other studies it has shown no benefits in PMS.

If you take GLA, you might want to take an EPA/DHA fish oil supplement with it.
A recent study suggested a slight increase in mammary carcinogenesis with GLA
alone, but not when taken with fish oil. (Fish oil alone reduced the risk of
mammary carcinogenesis.) Other studies suggested GLA may have anticancer effects.

Several studies suggest GLA can act as a 5 alpha-reductase inhibitor, and thus
lower DHT. However, those studies used free fatty acids, and were either in vitro
or topically applied to skin. Digesting borage oil or evening primrose oil has
no evidence of acting as a 5-alpha reductase inhibitor.

This has been shown to lower blood lipids, increase fat loss, and dramatically
improve acne at doses of 3-15gm. Such extreme doses may be unhealthy.
These doses are much higher than the RDI. High-doses of B5
can lower Biotin. Besides that, the only known side effect of pantothenic acid
at any dose is possible diarrhea. There is no known toxic dose of pantothenic
acid. Normal doses may also improve insulin sensitivity, and
inhibit TNF-alpha.

B5 deficiency can cause
depression and inadequate amounts of the brain chemical
acetylcholine. B5 is needed for hormone formation. The argument made in some
of the studies is that Pantothenic Acid is used by the body to make coenzyme-A.
Coenzyme-A is necessary for lipid metabolism, and for hormone formation. Hormone
formation is a high priority for the body, and the body will basically steal
B5 away from other functions, like processing oil in your skin. If the theory
is correct, since the body is making extra high levels of several hormones in
PCOS, it seems possible that stores of B5 would be low.

The adrenal glands also require Coenzyme-A. Large amounts of B5 are stored in
the adrenal glands. Stress can deplete the body of B5. B5 may be useful in treating
adrenal insufficiency, which may be associated with PCOS.

B5 is a popular treatment discussed in acne forums, and the alt.skincare.acne
newsgroup. It's efficacy and safety has been hotly debated over the last couple
years. Some are very enthusiastic about it. Others are wary of it safety based
on the fact that there are no multi-year long studies at these doses. There are
only a couple studies, lasting less than a year that were not very in-depth.

From antidotal evidence in acne forums, people responded to different doses, and the
few studies also suggest this.
For example, if acne has
cleared at 2gm, then one may be able to take even less. If acne does not
clear at 2gm, one may need more. After awhile at a dose that works, a lower maintenance
dose may be possible, so one could try a lower dose again after some time.

Calcium Pantothenate is not pure Pantothenic Acid. It is Calcium and Pantothenic
Acid. Calcium Pantothenate
contains 8.5% Calcium and 92% Pantothenic Acid. For each 1mg of Pantothenic Acid
from Calcium Pantothenate there is 0.093mg of calcium.

Pantethine is described as the active form of Pantothenic Acid (Vitamin B5). The
body creates Pantethine from Pantothenic Acid. Pantethine is necessary for the
metabolism of carbohydrates, proteins, and most importantly, fats. Several studies
have shown that Pantethine can significantly lower levels of both cholesterol
and triglycerides at doses of 600-1200mg. Though there are no studies directly
showing increased insulin sensitivity from Pantethine, there are studies showing
that when blood lipids level improve, it results in higher insulin sensitivity.

If it means anything, Atkins includes Pantethine in many of their supplement products.

Pantethine, which is a more direct precursor to coenzyme-A, may share many of
the same benefits of Vitamin B5, including improvement in acne and adrenal insufficiency.
In fact, if the theory is correct, Pantethine should be superior to B5 for acne.
However, anecdotal reports are that Pantethine is not as effective for acne as
high-dose B5. That may be because no one knows what dose of Pantethine to take
for acne since there are no studies on it. And, no one wants to experiement
with extremently high doses of Pantethine out of safety concerns.

Unfortunately, Pantethine is expensive.

Vitamin B12 : (Methylcobalamin)
1mg
Star rating: **

Folic Acid: (Folate)
1000mcg (1mg)
Star rating: **

Vitamin B6:
100mg
Star rating: **

Several studies show elevated homocysteine in PCOS. B12, Folic Acid and B6 all
work to lower Homocysteine. Metformin further increases homocysteine and is shown
to lower B12 and Folic Acid.

Methylcobalamin may be superior to other forms of b12 because it more
readily gets to the brain. But, any form should be fine.

Homocysteine is neurotoxic and accumulates in several neurological disorders.
B12, B6 and especially folic acid have all been shown to help treat neurological
disorders, including depression.

A study shows that oral contraceptives can lower B6, and that lower B6 can contribute
to depression.

Many studies show increased insulin sensitivity. It can increase energy and fat
loss, and lower TNF-alpha. It may be useful in
depression and improving cognitive
performance. Diabetics are often deficient in Carnitine, so it's likely lowered
in PCOS as well. It is often recommended to take amino acids on an empty stomach so
they will not compete for absorption with other protein. An animal study shows
that Acetyl-L-Carnitine increased ROS (Reactive Oxygen Species) production in
older animals. Lipoic Acid was shown to prevent the increased oxidative stress
caused by Acetyl-L-Carnitine.

Resveratrol:
20mg
Star rating: **

Many studies show Resveratrol lowers TNF-alpha and suppresses MMP-2 and MMP-9.
It is an excellent antioxidant.

Curcumin:
1600mg
Star rating: **

This is a potent anti-inflammatory. It reduces TNF-alpha, and down regulates MMP-9
and MMP-2. It has anticancer effects. It is an excellent antioxidant. Perhaps
its biggest drawback is that it is very poorly absorbed. Taking it with piperine
has been shown to dramatically improve absorption, and then a lower dose could
be used.

Vitamin K:
500mcg
Star rating: **

Vitamin K has been shown to be improve glucose tolerance, but the evidence is
scant. Vitamin K is sometimes recommended to take with calcium and vitamin D for osteoporosis,
and to keep calcium in the bones and not in blood vessels. Low vitamin
K intake has been shown to induce a poor early insulin response, and late hyperinsulinemia.
Doses range from 100mcg to 10mg. There does not seem to be consensus on what
the best dose is. The average diet gets between 300 and 500mcg per day.

*
1-Star Treatments

Vanadyl Sulfate is a more common and available form of Vanadium than BGOV. There
appears to be no safe and effective dose of Vanadyl Sulfate. Doses shown in studies
to be effective for insulin resistance and glucose tolerance are all 100mg or
more. Yet, there is concern that 10mg may cause kidney toxicity. I could not
find dose information for BGOV, but it is thought to be less toxic.

At any rate, Vanadium supplements may not be very effective in patients with PCOS
who are not yet diabetic. In one study, oral vanadyl sulfate improved insulin
sensitivity in NIDDM but not in obese non-diabetic subjects.

Studies show improved insulin sensitivity and improved glucose transport, others
show conflicting results. Pdrhealth.com notes "There are a few reports that
colosolic acid lowers blood glucose levels in type 2 diabetic subjects. However,
none of these reports has appeared in peer-reviewed scientific literature. ...
Currently, there is no credible evidence to support any claim for the use of
this substance in humans." Pdrhealth is sometimes a bit behind though. It
may be good, but more studies are needed.

L-Arginine:
2000mg (2gm)
Star rating: *

Several studies show increased insulin sensitivity and other improvements in diabetic
conditions. In some cases it may decrease TNF-alpha. Arginine is a precursor
to nitric oxide. PCOS is associated with decreased nitric oxide production.
Nitric oxide is a chemical messenger used in many reactions
in the body. Some believe that having extra nitric oxide available for your body to make when it
needs it can have a positive impact on many conditions. It's often recommended to
take amino acids on an empty stomach so they will not compete for absorption
with other protein.

This may be more useful for someone with high blood sugar. Hyperglycemia depletes
SOD and nitric oxide and arginine. Supplementing arginine has been shown to reverse
the inhibition of high glucose on nitric oxide production.

B-Complex:
Balanced formula
Star rating: *

It's often recommended to supplement the entire B-complex when supplementing any individual
B vitamins. Most of the B vitamins may be useful in treating
depression.

Astaxanthin:
4mg
Star rating: *

Astaxanthin is a carotenoid with strong antioxidant activity. It has also been
shown to have strong antiinflammatory activity and to inhibit TNF-alpha and suppress
I-kappa B kinase activity. It was shown to lower LDL and raise HDL cholesterol.
It may also be neuroprotective. There is some evidence that it may have anticancer
activity.

Vitamin E, especially Gamma E, has been shown to improve glycemic control, reduce
TNF-alpha, decrease PAI-1, and reduce C-Reactive Protein. Vitamin E deficiency
can increase MMP-2 and MMP-9 activity. It is a very good antioxidant. In one
study Vitamin E was shown to protect hypothalamic beta-endorphin neurons from
estradiol neurotoxicity, which may be an issue in PCOS.

Probiotics:
Star rating: *

A couple studies suggest there may be some blood glucose lowering effect. One
study suggests they may benefit fatty liver disease and lower TNF-alpha.
Another suggests that probiotics may promote leanness. Yogurt has probiotics
and there are some studies on weight loss and yogurt.

Quote: "We also speculate that changes in microbial
ecology prompted by Western diets, and or differences in microbial ecology between
individuals living in these societies, may function as an 'environmental' factor
that affects predisposition toward energy storage and obesity."

Nicotinamide is a no-flush form of the B vitamin Niacin. The other form of Niacin
is Nicotinic Acid. Nicotinamide may have benefits for PCOS distinct from Nicotinic
Acid.

Nicotinamide has been demonstrated, in one study, to affect glucose tolerance
and slowing down diabetes progression. However, these benefits may only apply
to type-1 diabetes.

Among other benefits, Nicotinamide has been shown to have antioxidant activity.
Nicotinamide has demonstrated a number of anti-inflammatory activities. Nicotinamide
has been shown to inhibit TNF-alpha. Nicotinamide may have a calming effect and
help with anxiety.

In one study, high doses of Niacin (1gm or more) were shown to increase Homocysteine.

Calcium Pyruvate has some evidence of increased insulin sensitivity, fat loss,
and lipid lowering effects. It may also have a positive effect on mood. The evidence
is not strong for any of its reported effects. Some human studies show no effect.
In studies that did show an effect on weight, the results were not impressive.
Doses used were bulky: 6-44gm Pyruvate (that's just Pyruvate, not Calcium Pyruvate).
6gm Pyruvate was shown to be somewhat effective when combined with exercise.
In powder form, this dose costs as little as $10/month.

There is minimal evidence that it can increase insulin sensitivity by reducing
oxidative stress. Low levels of vitamin C and produce
depression. OCPs can deplete
vitamin C. Low Vitamin C can raise PAI-1, and high doses were shown to lower
it.

Garlic Extract:
Star rating: *

Several studies show antidiabetic, blood sugar lowering, and antioxidant effects.
It may partly work by increasing insulin secretion. So, if you don't have high
blood sugar, this may or may not have as much benefit.

American Ginseng:
1gm per meal (taken with each meal)
Start rating: *

Several studies show improved insulin sensitivity, glucose disposal, and weight
loss. Apparently American Ginseng (Panax quinquefolius) is more effective for
hyperglycemia than the Asian varieties. Ginseng may also have an unwanted estrogenic
effect.

Zinc:
25mg
Star rating: *

There is some evidence of increased insulin sensitivity, and lowered TNF-alpha.
There is minimal evidence that these benefits are seen with zinc supplementation
even in those who are not zinc deficient. High doses of 50mg or more were shown
to elevate HbA1c levels, which is a sign of worsening diabetic symptoms. High
intakes of zinc will decrease copper absorption.

Selenium: (L-Se-Methylselenocysteine)
200mcg
Star rating: *

L-Se-Methylselenocysteine is probably the best form of Selenium to take, but any
common form should be fine. Several studies show increased insulin sensitivity,
and lowered TNF-alpha and C-Reactive Protein. Selenium may act as an insulin
mimic, but the evidence is weak.

TMG: (Trimethylglycine, Betaine)
2000mg
Star rating: *

This has been shown to reduce Homocysteine, treat
depression by raising SAMe levels,
and to treat and prevent nonalcoholic fatty liver disease. Insulin resistance
and obesity are major risk factors for the development of nonalcoholic fatty
liver disease, so it may be more common in PCOS. Doses in most studies range
from 6-20gm. However, doses between 1.5-3gm have also been shown to have an effect.
TMG is produced by the body. It is present in many foods but not in high amounts.

Tocotrienols have been shown to improve glycemic control and reduce TNF-alpha.
They are excellent antioxidants.

Coenzyme Q10:
100mg
Star rating: *

This has been shown to improve insulin resistance. However, there are several
other studies showing no benefit, and one showing negative results.

Gymnema Sylvestre: (gymnemic acid)
Star rating: -

This is shown to benefit diabetics who are not making enough insulin by causing
increased insulin secretion. Studies show it does not improve insulin resistance.
It has been shown not to cause hypoglycemia. So, it should not increase insulin
secretion in those who do not have high blood sugar, and it should not contribute
to hyperinsulinemia. This implies it will not be of any value if you don't have
high blood sugar.

Quercetin:
1000mg
Star rating: *

This has anti-inflammatory and antioxidant effects. It reduces TNF-alpha, and
inhibits MMP-9. It has benefits in some diabetic conditions.

Manganese:
2mg
Star rating: *

This has shown benefits in some diabetic conditions in combination with other
agents.

Potassium:
from food
Star rating: *

A Potassium deficient diet can lead to insulin resistance. Low potassium is also
implicated in depression.

If you are taking Spironolactone, you need to be careful with your Potassium intake.
Excessive potassium intake may cause hyperkalemia in patients receiving Spironolactone.

Avoid

CLA: (Conjuated Linoleic Acid)

This has conflicting evidence. Animal studies are encouraging, but some human
studies are negative.

Quote: "Overall, CLA appears to produce loss of fat mass and increase lean tissue
mass in rodents, but the results from 13 randomized, controlled short term (<6
months) trials in humans revealed only little evidence to support that CLA reduces
body weight or promotes repartitioning of body fat into fat free mass in man.
However, from mice and human studies there is increasing evidence that the CLA
isomer t10,c12 may produce liver hypertrophy and insulin resistance via a redistribution
of fat deposition that resembles lipodystrophy."

Quote: "A daily consumption of a drinkable dairy product containing up to 3 g
of CLA isomers for 18 weeks had no statistically significant effect on body composition
in overweight, middle-aged men and women."

A study out in June 2004 suggests it is beneficial for weight loss after 1 year.

This has been described as being "structurally similar to animal insulin". Too
high of a dose can cause hypoglycemia, which is further evidence that it acts
just like insulin. The problem is, if it's too much like insulin, then it may
contribute to insulin resistance and raise testosterone in PCOS. An insulin mimic
can be a good thing if it only increases glucose uptake without any of the negative
effects of insulin. This may be beneficial if you have high blood sugar.

Trans-Fats:

Trans-fats are especially bad -- worse even than saturated fats as far as their
impact on diabetes. Trans-fats have evidence of decreasing HDL and generally
increasing diabetes risk. Margarine is a major source of trans fatty acids. Reducing
trans fats has been show to reduce the risk of developing diabetes.

Saturated Fats:

If not offset by adequate monounsaturated fats, saturated fat can be toxic to
your pancreas by forming cerimide which kills pancreatic beta cells.

Fructose: (and high fructose corn syrup)

This is found in many junk foods. It may be worse than other sugars because it
has been shown to raise triglycerides.

High glycemic carbs:

High glycemic carbs, like white bread, pasta, etc., can be just as bad, or worse,
than refined sugar as far as its effect on insulin response and blood sugar.

Licorice:

It may do some good things. There are at least two
(supposedly there is a third somewhere) studies showing
lowered androgens and improved menstrual regularity and
ovulation. The problem is, it can dangerously raise blood
pressure. It can lower potassium to life threatening levels,
and cause fluid retention. If you plan to take this, you
might want to have doctor supervision. Note that Licorice
candy sold in the US does not have real licorice root in it
unless it says so, and then it may have been
deglycyrrhizinated, which may make it ineffective for PCOS
applications. So, you need to make sure you are taking an
effective form. If Licorice works by virtue of it being an
antiandrogen, you may be better off using a prescription
antiandrogen. Small doses are probably okay, but also
probably not effective for PCOS. Higher doses which may be
effective, appear dangerous.

Coffee, and the coffee fruit it's made from, contains caffeic acid and chlorogenic
acid. Chlorogenic acid was shown to inhibit glucose-6-phosphate translocase 1, which
is involved in intestinal glucose transport, and may slow glucose absorption, which
reduces the insulin response. However, some studies on whole coffee show a negative
impact on insulin sensitivity. Caffeic acid was shown to lower blood glucose by raising
insulin, which is not what you want to do in PCOS unless perhaps if you have high
blood sugar.

Purchasing these products from somewhere like iherb.com costs about $72 per month.
If you know of a cheaper source,
please email me.

The combination provides the following totals per day:

A (Beta-Carotene)

5000IU

C

240mg

E (d-alpha Succinate)

405IU

Thiamine

60mg

Riboflavin

30mg

Niacin (Niacinamide)

140mg

B6 (Pyridoxine HCl)

33mg

Folate (Folic Acid)

800mcg

B12 (Methylcobalamin)

80mcg

Biotin

3.2mg

Pantothenic Acid

120mg

Calcium

1186mg

Magnesium

740mg

Zinc

40mg

Selenium (L-Selenomethionine)

125mg

Copper

1.8mg

Manganese

5mg

Chromium (Chelavite, Aspartate)

800mcg

Potassium

100mg

Gymnema sylvestre

100mg

L-Carnitine

40mg

Inositol

30mg

Vanadium

18mcg

Vitamin D

200IU

Molybdenum

150mg

NAC

1800mg

EGCG

270mg

R-Lipoic Acid

400mg

EPA

1800mg

DHA

1200mg

Cinnamon

1/2tsp

Example Supplement
Regimen #2 (Powder)

Disclaimer: This example is not to be taken as advice. Consult your doctor
before using any treatments. Dosages or pill counts below may be inaccurate.

In this example we will be using supplements in powder form, where possible. Some
people would consider this choice pretty extreme. However, anyone who has baked cookies
and measured flour and sugar, can make a custom powder vitamin supplement.

Using supplements in powder form has several advantages. First, it allows for
exact dosing. You can adjust the amount of each powder to get the exact number
of milligrams you want. Second, it allows you to more easily choose the form
of each supplement you want to take. Third, it's faster to take vitamins in powder
form. With pills, you have to open each container, remember how many you are
supposed to take for that time of day, count out the number of pills, and swallow
each one with plenty of liquid. If you have 15 pills to take, that takes several
minutes and requires thought which can lead to mistakes ("Did I take 2 this morning,
or only one?"). With a powder, you have one container to open, take one scoop
(assuming you made a pre-measured scooper) and throw it into juice or other beverage,
stir and drink it -- there is no swallowing of pills, no counting, and it only
takes a matter of seconds. You can pre-mix several months worth at a time. Finally,
buying bulk powders tends to be cheaper than buying pills. Somewhere, pills started
out as powders. When you buy pills, you are paying the manufacturer to turn the
powder into pills. When buying powders, you can avoid having to pay that cost.

A disadvantage to powders is that you have to mix them beforehand. It would be
easy to make a mistake when combining the powders and end up taking the wrong
dose. You need to know what you are doing, and you have to get the numbers right.
Powders are difficult to measure accurately because some can be packed down and
it can be impossible to judge if you have measured correctly. To avoid this problem,
you can use a highly accurate digital scale, but using a scale is tedious. It
takes time to organize and measure each ingredient. It takes time to plan and
calculate how much needs to go into a batch and the volume of a single serving.
Some powders do not dissolve completely in water and you are left with stuff
floating in your drink. Finally, some powders are tasteless, but others can taste
pretty awful or are too alkali, or acidic and can burn your throat. Some things
are much better to take in a capsule.

This example includes the following products:

Powders (3 servings per day):

NOW Cal-Mag Citrate Powder (with Vitamin D)

330 mg per serving

B-A-C NAC Powder

600 mg per serving

B-A-C Green Tea Extract Powder (45% EGCG)

200 mg per serving

B-A-C Biotin Powder

3 mg mg per serving

B-A-C Folic Acid Powder

200 mcg per serving

Cinnamon Powder

1/6 tsp per serving

B-A-C Taurine Powder

500 mg per serving

B-A-C Acetyl-L-Carnitine Powder

230 mg per serving

B-A-C L-Arginine Powder

500 mg per serving

Pills:

NOW Vit-Min 75 2-A-Day

2 tablets per day

Country Life 100mg R-Lipoic Acid

4 capsules per day

NOW 200mg GFT Chromium (Chelavite)

4 tablets per day

NOW Super EPA

5 softgels per day

B-A-C is my abbreviation for beyond-a-century.com. Beyond-a-century sells many supplements
in powder form at cheap prices. The other products are often cheaper elsewhere. From
these sources, this regimen costs about $72 per month, which is the same price as
Regimen #1. If you know of a cheaper source,
please email me.

The combination provides the following totals per day:

Vitamin A (as Beta-Carotene)

10,000IU

Vitamin A (as Palmitate)

10,000IU

Vitamin C (as Ascorbic Acid)

250mg

Vitamin D (from Natural Fish Liver Oil)

850IU

Vitamin E (as d-alpha Tocopherol )

150IU

Thiamine (Vitamin B-1)

75mg

Riboflavin (Vitamin B-2)

75mg

Niacin (as Niacinamide)

75mg

Vitamin B-6 (as Pyridoxine HCl)

75mg

Folate (Folic Acid)

400mcg

Vitamin B-12 (as Cyanocobalamin)

100mcg

Biotin

9.1mg

Pantothenic Acid

75mg

Calcium (90% Citrate, Amino Acid Chelate, Oystershell)

1090mg

Iron (from Amino Acid Chelate)

10mg

Iodine (from Kelp)

150mcg

Magnesium (94% Citrate, Oxide, Amino Acid Chelate)

1050mg

Zinc (from Amino Acid Chelate)

15mg

Selenium (from Amino Acid Chelate)

25mcg

Copper (from Amino Acid Chelate)

1mg

Manganese (from Amino Acid Chelate)

5mg

Chromium (94% Chelavite, Yeast-free GTF)

850mcg

Molybdenum (from Amino Acid Chelate)

50mcg

Choline (from Choline Bitartrate)

100mg

Citrus Bioflavonoids (37% Hesperidin)

100mg

Inositol

75mg

PABA

30mg

Rutin

25mg

Betaine (as Betaine HCl)

25mg

Glutamic Acid

25mg

Boron (from Amino Acid Chelate)

500mcg

Nucleic Acid

50mg

NAC

1800mg

EGCG

270mg

R-Lipoic Acid

400mg

EPA

1800mg

DHA

1200mg

Cinnamon

1/2tsp

Taurine

1500mg

Acetyl-L-Carnitine

690mg

L-Arginine

1500mg

For the same price, this Regimen has several advantages over Regimen #1:

There are some disadvantages to this regimen. This contains less vitamin E and less
Molybdenum. This contains 10,000IU vitamin A palmitate, which is slightly high, and
is especially high for anyone who is pregnant or TTC. This contains only 25mcg of
Selenium and it is not Selenomethionine, whereas Regimen #1 contains 125mcg Selenomethionine.
If you have high blood sugar and you want to take Gymnema sylvestre, this Regimen
has none, whereas Regimen #1 contains 100mg. However, 100mg of Gymnema sylvestre
is possibly worthless as the dose is quite low.